CASE REPORT
Pericardial diverticula misdiagnosed as pericardial cysts Mary E. Money, MD, FACP,a,b and Chong Park, MD, FACS,c Baltimore and Hagerstown, Md, and Jefferson Borough, Penn
Supplemental material is available online.
Pericardial cysts, which result from complete closure of an embryonic pericardial defect, are believed to occur at a frequency of 1 in 100,000, based on a 1958 chest radiograph screening.1 Surgery is routinely not recommended, unless obvious compression of adjacent organs is demonstrated. However, 10% of all cysts may be instead a pericardial diverticulum with a persistent connection to the pericardial space, not apparent from radiologic studies, and identified only at surgery.2 These lesions may cause atypical symptoms that are relieved only after surgery, as demonstrated by this case report. CASE REPORT A 66-year-old retired biologist was diagnosed in 1984 with an ‘‘enlarged fat pad,’’ by chest radiograph. Chest computed tomography (CT) scans revealed a right, cardiophrenic, 2.5-cm, soft-tissue cystic mass that had increased to 7.3 cm by 2008 (Figure 1). Additional studies included: standard cardiac exercise stress tests in 1989, 1993, and 1998 (all normal); exercise stress tests with images in 2001 and 2008 (all normal); cardiac catheterization in 2003 (negative for significant disease); echocardiograms in 2001, 2005, and 2008 (mild mitral insufficiency); 24hour Holter monitors in 1993 and 2001 (normal); cardiac magnetic resonance imaging in 2008; negative testing for pheochromocytoma in 2010; and a magnetic resonance imaging echocardiogram in 2012 (a 4.7 3 3.6 3 4.1 cm ‘‘pericardial cyst’’ without evidence of compression). Intermittent, daytime, anterior chest symptoms, not affecting the patient’s usual activities, were characterized as follows: nonradiating; unrelated to activity, inspiration, From the Department of Internal Medicine,a University of Maryland School of Medicine, Baltimore; Department of Internal Medicine,b Meritus Medical Center, Hagerstown, Md; and Heart Institute at Jefferson Regional Medical Center,c Allegheny Health Network, Jefferson Borough, Penn. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 13, 2014; revisions received Dec 13, 2014; accepted for publication Jan 16, 2015. Address for reprints: Mary E. Money, MD, FACP, Drs Waldman & Money, PA, 354 Mill St, Hagerstown, MD 21740 (E-mail: [email protected]). 0022-5223 Copyright Ó 2015 by The American Association for Thoracic Surgery. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jtcvs.2015.01.032
or position; duration from minutes to hours; and intensity of 2 to 5 on a scale of 0 to 10. Different nocturnal symptoms occurred lasting 2-12 hours: over 90% of the episodes woke her from sleep: forceful heart pounding, intense anxiety, tachycardia, inability to lie back down, mild chest discomfort sometimes, but without dyspnea, nausea, indigestion, flushing or diaphoresis. The episodes were not related to exercise, stress at work, the sudden death of her husband, eating, drinking, sexual activity, or urinating or bowel habits. Frequency was not predictable, either for the vague daytime chest discomfort, or the nocturnal attacks, which both ranged from being weekly episodes, to years apart. Empiric treatment with beta-blockers for presumed supraventricular tachycardia decreased her heart rate, but did not lessen the other symptoms that accompanied the nocturnal attacks. Antianxiety medications did not abort them. Symptoms began to increase in the spring of 2012. A portable electrocardiogram monitor recorded a normal sinus rhythm with a narrow complex during a night attack. Severe episodic fatigue attacks lasting
Pericardial diverticula misdiagnosed as pericardial cysts Mary E. Money, MD, FACP,a,b and Chong Park, MD, FACS,c Baltimore and Hagerstown, Md, and Jefferson Borough, Penn
Supplemental material is available online.
Pericardial cysts, which result from complete closure of an embryonic pericardial defect, are believed to occur at a frequency of 1 in 100,000, based on a 1958 chest radiograph screening.1 Surgery is routinely not recommended, unless obvious compression of adjacent organs is demonstrated. However, 10% of all cysts may be instead a pericardial diverticulum with a persistent connection to the pericardial space, not apparent from radiologic studies, and identified only at surgery.2 These lesions may cause atypical symptoms that are relieved only after surgery, as demonstrated by this case report. CASE REPORT A 66-year-old retired biologist was diagnosed in 1984 with an ‘‘enlarged fat pad,’’ by chest radiograph. Chest computed tomography (CT) scans revealed a right, cardiophrenic, 2.5-cm, soft-tissue cystic mass that had increased to 7.3 cm by 2008 (Figure 1). Additional studies included: standard cardiac exercise stress tests in 1989, 1993, and 1998 (all normal); exercise stress tests with images in 2001 and 2008 (all normal); cardiac catheterization in 2003 (negative for significant disease); echocardiograms in 2001, 2005, and 2008 (mild mitral insufficiency); 24hour Holter monitors in 1993 and 2001 (normal); cardiac magnetic resonance imaging in 2008; negative testing for pheochromocytoma in 2010; and a magnetic resonance imaging echocardiogram in 2012 (a 4.7 3 3.6 3 4.1 cm ‘‘pericardial cyst’’ without evidence of compression). Intermittent, daytime, anterior chest symptoms, not affecting the patient’s usual activities, were characterized as follows: nonradiating; unrelated to activity, inspiration, From the Department of Internal Medicine,a University of Maryland School of Medicine, Baltimore; Department of Internal Medicine,b Meritus Medical Center, Hagerstown, Md; and Heart Institute at Jefferson Regional Medical Center,c Allegheny Health Network, Jefferson Borough, Penn. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 13, 2014; revisions received Dec 13, 2014; accepted for publication Jan 16, 2015. Address for reprints: Mary E. Money, MD, FACP, Drs Waldman & Money, PA, 354 Mill St, Hagerstown, MD 21740 (E-mail: [email protected]). 0022-5223 Copyright Ó 2015 by The American Association for Thoracic Surgery. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jtcvs.2015.01.032
or position; duration from minutes to hours; and intensity of 2 to 5 on a scale of 0 to 10. Different nocturnal symptoms occurred lasting 2-12 hours: over 90% of the episodes woke her from sleep: forceful heart pounding, intense anxiety, tachycardia, inability to lie back down, mild chest discomfort sometimes, but without dyspnea, nausea, indigestion, flushing or diaphoresis. The episodes were not related to exercise, stress at work, the sudden death of her husband, eating, drinking, sexual activity, or urinating or bowel habits. Frequency was not predictable, either for the vague daytime chest discomfort, or the nocturnal attacks, which both ranged from being weekly episodes, to years apart. Empiric treatment with beta-blockers for presumed supraventricular tachycardia decreased her heart rate, but did not lessen the other symptoms that accompanied the nocturnal attacks. Antianxiety medications did not abort them. Symptoms began to increase in the spring of 2012. A portable electrocardiogram monitor recorded a normal sinus rhythm with a narrow complex during a night attack. Severe episodic fatigue attacks lasting
